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507 N. Sam Houston Pkwy E. Ste. 505

Houston, Texas 77060

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Commercial Insurance Quote

Commercial Insurance Quote

Safeguarding Your Future with S. Galloway Agency, Inc.

Commercial Insurance Questionnaire - Quote

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COMMERCIAL INSURANCE QUESTIONNAIRE

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APPLICANT NAME (INDIVIDUAL REQUESTING QUOTE)*

First Name

Last Name

Email

Phone

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Applicant role in the business (Owner, Administrator, etc.)*

Company/Organization Name*

Legal Entity*

Business established date*

FEIN*

USDOT (if applicable)*

Type of Business (Restaurant, Garage, Retail, Construction, etc.)*

Number of full-time employees*

Number of part-time employees*

Gross Annual payroll expense ($)*

Do you need coverage for a specific vehicle you will use in this business?*

Yes

No

If YES, please list the year, make and model of the vehicle(s) to be covered. If NO, list n/a.*

If there are drivers to be covered, please list the name, DOB and driver's license number of the driver(s) to be covered (include yourself). If NO, list n/a.*

Detailed information about your business (Primary function)*

Gross Annual Revenue ($)*

Insurance coverage requested*

Current Insurance Carrier*

Current Policy Expiration Date

Current Policy Retroactive Date

Desired Effective Date for New Policy*

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PROPERTY DETAILS

Are you requesting Property Coverage (for property in OR near the building)*

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BUILDING INFORMATION (IF APPLICABLE)

Construction Type (of building)

Year Built

Insured sq feet

Unoccupied sq feet

Year Renovated

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RENOVATED YEAR

Roof

Electrical

Plumbing

Heating

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BUILDING SECURITY

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Local

Central

None

Burglar Alarm

Local

Central

None

Estimated Building Property Value ($)

Estimated Personal Property Value ($)

Estimated Personal Property Value ($)

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GENERAL LIABILITY

Are you requesting General Liability Coverage

Desired Aggregate Amount of General Liability Coverage ($)

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If applicable, answer the following questions

Are any autos used exclusively for business use?

Do any employees use a personal auto for business use?

Are any web based services offered?

Are credit card payments accepted?

Is there a program to identify identity theft?

Is there Underground Tank Leakage Exposure?

Is there a Pollution Exposure?

Yes

No

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PROFESSIONAL LIABILITY

Are you requesting Professional Liability Coverage?

Desired Amount of Professional Liability Coverage ($)

Describe Professional Services offered?

Does your firm provide services outside the U.S.?

Percentage of Services for the outside the U.S

Is there a formal Safety Plan?

Does your firm use Independent Contractors (ICs) or Sub Contractors?

What is the percentage of your firm’s gross Fees paid to ICs or Sub Contractors last year?

Do you request Certificates of Insurance from ICs and Sub Contractors?

Do you have written agreements on every project?

Do ICs and Sub Contractors have written agreements?

Do you provide Professional Liability to your ICs and Sub Contractors?

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MEDICAL PROFESSIONAL LIABILITY

Are you requesting Medical Professional Liability Coverage?

Desired Amount of Medical Professional Liability Coverage ($)

Describe Medical Professional Services offered

Do you employ Physicians or Surgeons?

Is there a Medical Director?

Do you have written agreements on every project?

Does the Medical Director have their own insurance?

Do you request Certificates of Insurance from ICs and Sub Contractors?

Do ICs and Sub Contractors have written agreements?

Do you provide Professional Liability to your ICs and Sub Contractors?

Do you bill for Medicare/Medicaid?

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WORKERS' COMPENSATION

Are you requesting Workers’ Compensation Coverage?

Yes

No

Number of Independent Contractors (ICs)

Number of Independent Contractors (ICs)

Full-time

Part-time

Are Medical Benefits Offered?*

Do you offer Paid Vacation?*

Is there a formal Safety Program?*

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REQUEST A QUOTE

CONTACT DETAILS

S. Galloway Agency, Inc.

Office: 507 N. Sam Houston Pkwy E. Ste. 505

Houston TX 77060

Phone Number: 281-886-7125

Email: info@insuredwithserena.com

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BUSINESS HOURS

Monday: 9:00 am - 6:00 pm
Tuesday: 9:00 am - 6:00 pm
Wednesday: 9:00 am - 6:00 pm
Thursday: 9:00 am - 6:00 pm
Friday: 9:00 am - 3:00 pm
Saturday: 10:00 am - 2:00 pm
Sunday: Closed

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